What is the recommended treatment for gonorrhea in a patient with a penicillin allergy?

Gonorrhea Treatment in Patients with Penicillin Allergy

For patients with penicillin allergy requiring gonorrhea treatment, use ceftriaxone 250 mg intramuscularly as a single dose plus azithromycin 1 g orally, as cephalosporins can be safely administered to most penicillin-allergic patients due to low cross-reactivity (approximately 1-3%). 1, 2

Primary Treatment Approach

The standard gonorrhea regimen remains appropriate for most penicillin-allergic patients because:

• Ceftriaxone is a cephalosporin, not a penicillin, and true cross-reactivity between penicillins and third-generation cephalosporins is rare 3
• The recommended regimen is ceftriaxone 125-250 mg intramuscularly plus azithromycin 1 g orally as a single dose 3, 1
• This dual therapy addresses both gonorrhea and presumptive chlamydial co-infection 3, 2

For Severe Cephalosporin Allergy

If the patient has a documented severe cephalosporin allergy or anaphylaxis to beta-lactams:

Use azithromycin 2 g orally as a single dose 1, 2

Critical Requirements with Azithromycin Monotherapy:

• Perform test-of-cure 1 week after treatment using culture (preferred) or NAAT 1, 2
• Culture is preferred because it allows antimicrobial susceptibility testing 1, 2
• Consult an infectious disease specialist due to limited data on alternative regimens 2
• Report suspected treatment failures to local public health officials within 24 hours 1, 2

Important Caveats About Azithromycin:

• Gastrointestinal adverse events are common with the 2 g dose 4
• Resistance concerns exist, particularly in certain geographic areas 5
• Azithromycin 1 g is insufficient as monotherapy and should not be used 3

Additional Alternative Regimens

For uncomplicated urogenital and anorectal infections when cephalosporins cannot be used:

• Spectinomycin 2 g intramuscularly as a single dose (cure rate 98.2%) 1
• Gentamicin 240 mg intramuscularly plus azithromycin 2 g orally (100% cure rate in clinical trials) 4
• Gemifloxacin 320 mg orally plus azithromycin 2 g orally (99.5% cure rate) 4

Critical Limitation of Spectinomycin:

• Only 52% effective against pharyngeal gonorrhea 3, 1
• Requires pharyngeal culture 3-5 days post-treatment if pharyngeal infection suspected 3

Quinolone Considerations

Quinolones should NOT be routinely used due to widespread resistance 3

Only consider quinolones if:

• Antimicrobial susceptibility testing confirms susceptibility 1
• Options include ciprofloxacin 500 mg orally or levofloxacin 250 mg orally 3

Site-Specific Treatment Considerations

Pharyngeal Gonorrhea:

• More difficult to eradicate than urogenital infections 3, 1
• Ceftriaxone remains most effective 3
• Spectinomycin is inadequate (52% efficacy) 3, 1
• Gentamicin/azithromycin cured 10/10 pharyngeal infections in trials 4
• Gemifloxacin/azithromycin cured 15/15 pharyngeal infections 4

Disseminated Gonococcal Infection:

• Ceftriaxone 1 g IM/IV daily for ≥1 week 3
• Alternative: Spectinomycin 2 g IM every 12 hours for ≥1 week 3

Gonococcal Conjunctivitis:

• Ceftriaxone 1 g intramuscularly as single dose 3
• Consider saline lavage of infected eye 3

Essential Management Steps

Partner Management:

• Evaluate and treat all sex partners from preceding 60 days 1, 2
• Patients must avoid sexual intercourse until therapy completed and both partners asymptomatic 1, 2
• Consider expedited partner therapy if partner treatment cannot be ensured 2

Co-infection Treatment:

• Always treat presumptively for chlamydia unless ruled out 3, 2
• Use azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days 3

Follow-up Testing:

• Test-of-cure required only for alternative regimens (not standard ceftriaxone) 3
• Retest all patients at 3 months due to high reinfection rates 3
• If 3-month follow-up unlikely, retest whenever patient returns within 12 months 3

Special Populations

Pregnancy:

• Pregnant women with penicillin allergy should receive ceftriaxone (cross-reactivity risk is acceptable) 3
• Spectinomycin 2 g intramuscularly is alternative if cephalosporin absolutely contraindicated 3
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 3, 2
• For chlamydia co-treatment: use erythromycin or amoxicillin 3, 2

HIV-Infected Patients:

• Use same treatment regimens as HIV-negative patients 3
• Exercise caution with alternative regimens as data are limited 3

Common Pitfalls to Avoid

• Do not assume penicillin allergy precludes cephalosporin use—most patients can safely receive ceftriaxone 1, 2
• Do not use azithromycin 1 g as monotherapy—insufficient efficacy 3
• Do not use quinolones without susceptibility testing—resistance is widespread 3, 1
• Do not forget test-of-cure with alternative regimens—treatment failure monitoring is essential 1, 2
• Do not neglect chlamydia co-treatment—co-infection rates are high 3, 2